Medicare Secondary Payer (MSP) Billing No. Yes. Yes. Yes. Yes

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1 Does an MSP record appear on the beneficiary s ELGA/ELGH file? Medicare Secondary Payer (MSP) Billing Do your dates of service fall within the effective and term dates on the MSP record? Is the MSP record for Working Aged insurance? Is the MSP record for -fault or Liability? Is the MSP record for Workers Compensation? Is the MSP record for Black Lung? Is the MSP record for VA? Is the MSP record for disability? Is the MSP record for PHS or other Federal Agency? Is the MSP record for ESRD? Are your services related to this record? Are your services related to this record? Bill Medicare as primary using Process E. Does it appear your services may be related to Black Lung? Bill Medicare conditionally using process F. Were VA benefits used by the beneficiary? Are you aware of an MSP situation? Submit claim to Medicare as primary. WA insurance is primary. Bill this insurance. If insurer pays, bill Medicare secondary using Process A. If payment denied, applied to deductible, or not paid promptly, bill Medicare conditionally using Process H. This insurance is primary. Bill this insurance. If insurer pays, bill Medicare secondary using Process B. If payment denied, bill Medicare conditionally using Process C. If no response from insurer, bill Medicare conditionally using Process D. Is the case in litigation? Bill Medicare as primary using Process E. You may bill Medicare conditionally using Process D. WC insurance is primary. Bill the WC insurance. If insurer pays, bill Medicare secondary using Process B. If payment denied, bill Medicare conditionally using Process C. If set-aside arrangement was established, bill the administrator of set-aside arrangement. Disability insurance is primary. Bill this insurance. If insurer pays, bill Medicare secondary using Process A. If payment denied, applied to deductible, or not paid promptly, bill Medicare secondary using Process H. Were you authorized by PHS or Federal Agency for the services? Bill Department of Labor (DOL). If payment in full, no Medicare payment can be made. If DOL denies some/all services, bill Medicare conditionally using Process F. Bill VA for the services. If payment in full, no Medicare payment can be made. If a VA co-pay is due, bill Medicare secondary using Process G. Bill Medicare conditionally using Process G. The GHP is primary. Submit your claim to the GHP. If payment denied, applied to deductible, or not paid promptly, bill Medicare conditionally using Process J. NOTE: If ELGH/ELGA lists multiple records, use chart for each record shown. If ELGH/ELGA record is incorrect, contact COB contractor at Contact the COBC at Bill PHS. If payment in full, no Medicare payment can be made. Bill Medicare conditionally using Process I. J a n u a r y 2010 C a h a b a G B A, L L C P a g e 1 o f 11

2 Process A: Working Aged or Disability insurance is primary. Billing Medicare secondary. Submit your claim to the primary insurance. After receiving payment from the primary insurance, you may bill Medicare secondary using the following instructions. Enter the value codes 12 to indicate Working Aged insurance, or 43 to indicate Disability insurance and the amount you were paid by the primary insurance. Enter value code 44 and amount if you are contractually obligated to accept an amount less than the total charges as your payment in full. Bill any other value code as usual. 3 CD Enter payer code A if working aged or G if disability on line A. Enter payer code Z on line B. 3 OSCAR FL 1 Enter your provider number for the primary payer (if known), on line A. 4 REMARKS FL Enter the employer s name and address that provides the primary insurance. Enter the Insured s name (the name of the employee that carries the working aged/disability insurance) on line A. Enter the beneficiary s name on line B. SEX Enter the insured s sex code (F or M) on line A. Enter the beneficiary s sex code on line B. DOB Enter the insured s date of birth (MMDDCCYY) on line A. Enter the beneficiary s DOB on line B. REL FL 9 CERT-SSN-HIC FL 0 Enter the code for the patient s relationship to the insured on line A. (See MSP Billing Codes below.) Enter the primary payer s policy number (if available on ELGA) on line A. Enter the beneficiary s HIC number on line B. GROUP NAME FL 1 Enter the group name or plan through which the insurance is provided on line A (if known). FL 2 CITY, ST, ZIP Enter the insurance group number of the plan through which the insurance is provided on line A (if known). J a n u a r y 2010 C a h a b a G B A, L L C P a g e 2 o f 11

3 Process B: Services related to -fault, Liability or Workers Compensation (WC) record. Primary insurer billed and payment received. Billing Medicare secondary. 3 CD Enter the appropriate occurrence code (01 for med-pay, 02 for no fault, 03 for liability, under- or un-insured, or 04 for WC) and date of accident/injury based on the MSP record. (See MSP Billing Codes below.) Enter the appropriate value code (14 for no-fault/med-pay, 47 for liability or 1 for WC) and the amount you were paid by the insurer. Enter value code 44 and amount if you are contractually obligated to accept an amount less than the total charges as your payment in full. Enter the appropriate payer code (D for no fault/med-pay, L for liability, E for WC) on line A. Enter payer code Z on line B. 4 REMARKS FL 80 / Enter remarks indicating services related to accident. Billing Medicare secondary. If WC, also enter employer s name and address. Include any other pertinent information (i.e. claim number). Enter the insured s name (the name of the person/business that carries this insurance) on line A. Enter the beneficiary s name on line B. SEX Enter the insured s sex code (F or M) on line A. Enter the beneficiary s sex code on line B. DOB Enter the insured s date of birth (MMDDCCYY) on line A. Enter the beneficiary s DOB on line B. REL FL 9 CERT-SSN-HIC FL 0 Enter the code for the patient s relationship to the insured on line A. (See MSP Billing Codes below.) Enter the appropriate patient relationship code (18 for self, 20 if employee, 41 injured plaintiff or 21 for unknown) on line A. Enter the primary payer s policy number (if available on ELGA) on line A. Enter the beneficiary s HIC number on line B. GROUP NAME FL 1 Enter the group name or plan through which the insurance is provided on line A (if known). FL 2 Enter the insurance group number of the plan through which the insurance is provided on line A (if known). J a n u a r y 2010 C a h a b a G B A, L L C P a g e 3 o f 11

4 Process C: Services related to -fault, Liability, or Workers Compensation (WC) record. Primary insurer billed and denial received (e.g. insurance denied payment, benefits exhausted. Billing Medicare conditionally. Enter occurrence code 24 and the date the insurer denied payment. Enter the appropriate occurrence code (01 for med-pay, 02 for no fault, 03 for liability, under- or un-insured, or 04 for WC) and date based on the MSP record. (See MSP Billing Codes below.) Bill any other occurrence codes as usual. Enter the appropriate value code (14 for no-fault, 47 for liability, 1 for workers compensation). Enter zeros ( ) in the amount field. Bill any other value codes as usual. 3 CD Enter payer code C on line A. Enter payer code Z on line B. 4 REMARKS FL 80 / Enter a remark to indicate services denied by primary insurer and the reason for denial. If WC, also enter employer name and address. Enter the insured s name (the name of the person/business that carries this insurance) on line A. Enter the beneficiary s name on line B. SEX Enter the insured s sex code (F or M) on line A. Enter the beneficiary s sex code on line B. DOB Enter the insured s date of birth (MMDDCCYY) on line A. Enter the beneficiary s DOB on line B. REL FL 9 CERT-SSN-HIC FL 0 Enter the code for the patient s relationship to the insured on line A. (See MSP Billing Codes below.) Enter the primary payer s policy number (if available on ELGA) on line A. Enter the beneficiary s HIC number on line B. GROUP NAME FL 1 Enter the group name or plan through which the insurance is provided (f known). FL 2 Enter the insurance group number of the plan through which the insurance is provided on line A (if known). J a n u a r y 2010 C a h a b a G B A, L L C P a g e 4 o f 11

5 Process D: Services related to -fault, Liability or Workers Compensation (WC) record. Primary insurer billed, and no response received from insurer. If WC, case is in litigation. Billing Medicare conditionally. If you have submitted your claim to the primary insurance, and have not received a response from the no-fault/liability insurer AND 120 days have passed since your first date of service, you may bill Medicare conditionally using the following instructions. If WC, you must withdraw any lien filed against a pending settlement. 1 COND CODES FL If WC, enter condition code 02 to indicate the condition is employment related. Enter occurrence code 24 and the date of last contact with the insurance/attorney. Enter the appropriate occurrence code (01 for med-pay, 02 for no fault, 03 for liability, under- or uninsured, or 04 for WC) and date based on the MSP record. Enter appropriate value code (14 for no-fault, 47 for liability or 1 for WC. Enter zeros ( ) for the amount. 3 CD FL 0 Enter the payer code C on line A. Enter payer code Z on line B for Medicare. 4 REMARKS FL 80 / Enter a remark to indicate no response from primary insurer, and billing Medicare conditionally. If WC, also enter employer s name and address. If an attorney is involved, enter the name and address. Enter the insured s name (the name of the person/business that carries this insurance) on line A. Enter the beneficiary s name on line B. SEX Enter the insured s sex code (F or M) on line A. Enter the beneficiary s sex code on line B. DOB Enter the insured s date of birth (MMDDCCYY) on line A. Enter the beneficiary s DOB on line B. REL FL 9 Enter the code for the patient s relationship to the insured on line A. (See MSP Billing Codes below.) CERT-SSN-HIC FL 0 Enter the primary payer s policy number (if available on ELGA) on line A. Enter the beneficiary s HIC number on line B. GROUP NAME FL 1 Enter the group name or plan through which the insurance is provided on Line A (if known). FL 2 Enter the insurance group number of the plan through which the insurance is provided on line A (if known). J a n u a r y 2010 C a h a b a G B A, L L C P a g e o f 11

6 Process E: Services unrelated to -fault, Liability or Workers Compensation record. Billing Medicare Primary. (See te below.) A no-fault, liability or workers compensation record appears on ELGH/ELGA, which overlaps the dates of service for which you are billing. However, your services are unrelated to this record and there are no trauma diagnoses (i.e or E-codes) on the claim. You must bill Medicare indicating your services are unrelated to the record. Do not enter any occurrence code or date Do not enter any value code. 3 CD Enter payer code Z on Line A for Medicare. 4 REMARKS FL 80 Enter a remark to indicate services are unrelated to record on ELGH/ELGA. If your claim includes a trauma diagnosis (i.e or E-code) which is unrelated to the current record on ELGA, and there is no other insurer liable, bill your claim using the following chart. Enter occurrence code 0 and the date of the accident/injury Do not enter any value code 3 CD Enter payer code Z on Line A for Medicare. 4 REMARKS FL 80 Enter a remark to explain why there is no other insurer liable. NOTE: If your claim includes a trauma diagnosis (i.e or E-code) which is unrelated to the current record on ELGA, and another insurer is liable, contact the COBC ( ) to report the accident. Bill the claim using Process B (if other insurer had paid) or Process D (if other insurer has not paid and you are billing conditionally). J a n u a r y 2010 C a h a b a G B A, L L C P a g e o f 11

7 Process F: Services do not appear related to Black Lung OR Services related to Black Lung and some/all services were denied by Department of Labor (DOL) (see te below). Billing Medicare conditionally. If services were denied by DOL, enter occurrence code 24 and the date of the denial. Enter value code 41. Enter zeros ( ) if all services denied, or if services unrelated to BL. If DOL denied some services, enter the amount paid by DOL. 3 CD If services are unrelated to BL, or DOL denied all services, enter payer code C on line A. If DOL denied some services, enter payer code H on line A. Enter payer code Z on line B. 3 PAYER FL 0 Enter name of black lung insurer (as it appears on ELGA) on line A. Enter Medicare on line B. 4 REMARKS FL 80 If services are unrelated to BL, enter a remark to indicate why the services are unrelated. If services were denied by DOL, the claim must include DOL s denial notice (see te below). Enter the beneficiary s name in the insured s name field on line A and B. SEX Enter the insured s sex code (F or M) on line A. Enter the beneficiary s sex code on line B. DOB Enter the insured s date of birth (MMDDCCYY) on line A. Enter the beneficiary s DOB on line B. REL FL 9 Enter the code for the patient s relationship code 18 on line A. CERT-SSN-HIC FL 0 Enter the patient s Black Lung Identification number on Line A. Enter the beneficiary s HIC number on line B. GROUP NAME FL 1 Enter the group name or plan through which the insurance is provided on Line A (if known). NOTE: If the services appear to be related to Black Lung, they must be billed to Department of Labor (DOL) before billing Medicare. If services are denied by DOL, a hardcopy claim must be submitted to Medicare. A copy of DOL s denial notice, giving the specific reason for nonpayment, must be included with your hardcopy claim, and mailed to: Alabama Providers Georgia Providers Tennessee Providers Alabama Part A Claims Attention: Adjustment Clerk PO Box Birmingham, AL Georgia Part A Claims Attention: Adjustment Clerk PO Box Birmingham, AL Tennessee Medicare Part A Claims Attention: Adjustment Clerk PO Box 114 Birmingham, AL J a n u a r y 2010 C a h a b a G B A, L L C P a g e 7 o f 11

8 Process G: Veterans Administration benefits were not used. Billing Medicare conditionally. OR A co-pay is due to VA. Billing Medicare secondary. If VA benefits were not used, or if VA did not pay, enter occurrence code 24 and the date the patient opted not to use VA coverage, or the date of the denial. If VA benefits were not used, or if no payment was made by VA, enter value code 42 and zeros ( ) for the amount. If some services were paid by the VA, enter value code 42 and the amount authorized/paid by VA, and enter value code 44 and amount if you are contractually obligated to accept an amount less than the total charges as your payment in full.. 3 CD If VA benefits were not used, or if no payment was made by VA, enter payer code C on line A. If some services were paid by VA, enter payer code I on line A. Enter payer code Z on line B. 3 PAYER FL 0 Enter Veterans Administration in the payer name field on line A. Enter Medicare on line B. 4 REMARKS FL 80 Enter remark to indicate billing Medicare conditionally/secondary and reason why. Enter the beneficiary s name in the insured s name field on line A and B. SEX Enter the beneficiary s sex code (F or M) on line A and B. DOB Enter the beneficiary s date of birth (MMDDCCYY) on line A and B. REL FL 9 Enter the patient relationship code 18 on line A. CERT-SSN-HIC FL 0 Enter the Veteran s Administration identification number on line A. Enter the beneficiary s HIC number on line B. Enter the Veteran s Administration address, city, state and zip (as it appears on ELGA). J a n u a r y 2010 C a h a b a G B A, L L C P a g e 8 o f 11

9 Process H: Disability insurance OR Working Aged insurance is primary and payment denied, applied to deductible or not paid promptly. Billing Medicare conditionally. Enter occurrence code 24 and the date of Explanation of Benefits (EOB) or date of last contact with the insurer. Enter the appropriate value code (43 for disability or 12 for Working Aged). Enter zeros ( ) in the amount field. Also, enter value code 44 and amount if you are contractually obligated to accept an amount less than the total charges as your payment in full. 3 CD Enter payer code C on line A. Enter payer code Z on line B. 4 REMARKS FL 80 / Enter a remark to indicate reason why no payment was made. Enter the employer s name and address that provides the primary insurance. Enter the insured s name (name of the person that carries the disability insurance) on line A. Enter the beneficiary s name on line B. SEX Enter the insured s sex code (F or M) on line A. Enter the beneficiary s sex code on line B. DOB Enter the insured s date of birth (MMDDCCYY) on line A. Enter the beneficiary s DOB on line B. REL FL 9 Enter the code for the patient s relationship to the insured on line A. (See MSP Billing Codes below.) CERT-SSN-HIC FL 0 Enter the primary payer s policy number on line A. Enter the beneficiary s HIC number on line B. GROUP NAME FL 1 Enter the group name or plan through which the insurance is provided (if known). Enter the insurance group number of the plan through which the insurance is provided on line A (if FL 2 known). CITY, ST, ZIP Process I: Public Health Services (PHS) or other Federal Agency is primary. Services were not authorized or are unrelated to PHS/Federal Agency. Billing Medicare conditionally. Enter occurrence code 24 and the date the services were denied, or the date you determined the services were unrelated. Enter the value codes 1 to indicate PHS. Enter zeros ( ) in the amount field. 3 CD Enter payer code C on Line A. Enter payer code Z on line B. 4 REMARKS FL 80 / Enter a remark to indicate reason why services are unrelated or were not covered by PHS/other Federal Agency. Enter the beneficiary s name in the insured s name field on line A and B. SEX Enter the beneficiary s sex code on line A and B. DOB Enter the beneficiary s DOB on line A and B. REL FL 9 Enter the patient relationship code 18 on line A. CERT-SSN-HIC FL 0 Enter the PHS/Federal Agency identification number on line, if available. Enter the beneficiary s HIC number on line B. J a n u a r y 2010 C a h a b a G B A, L L C P a g e 9 o f 11

10 Process J: Group Health Plan (GHP) is primary for 30-month ESRD coordination period. Primary insurer billed and payment/denial received, applied to deductible, or not paid promptly. Billing Medicare conditionally. (Services after the 30-month coordination period are billed to Medicare as primary.) 3 CD Enter occurrence code 33 and date 30-month coordination period started. If services denied, applied to deductible, or not made promptly, also enter occurrence code 24 and the date of the explanation of benefits (EOB) or date of last contact with primary insurer. Enter value code 13. Enter the amount paid by GHP. Enter zeros ( ) if the services were denied by the GHP, applied to deductible, or not made promptly. Enter value code 44 and amount if you are contractually obligated to accept an amount less than the total charges as your payment in full. Enter payer code B on Line A if primary insurer paid. Enter payer code C if primary insurer payment denied, applied to deductible, or not made promptly. Enter payer code Z on line B. 3 PAYER FL 0 Enter the primary insurer s name (as it appears on ELGA) on line A. Enter Medicare on line B. 4 REMARKS FL /80 Enter the employer s name and address that provides the primary insurance. If no payment was made, enter a remark to explain why no payment was made. Enter the insured s name (the name of the person that carries this insurance) on line A. Enter the beneficiary s name on line B. SEX Enter the insured s sex code (F or M) on line A. Enter the beneficiary s sex code on line B. DOB Enter the insured s date of birth (MMDDCCYY) on line A. Enter the beneficiary s DOB on line B. REL FL 9 Enter the code for the patient s relationship to the insured on line A. CERT-SSN-HIC FL 0 Enter the primary payer s policy number on line A. Enter the beneficiary s HIC number on line B. GROUP NAME FL 1 Enter the group name or plan through which the insurance is provided on Line A (if known). FL 2 Enter the insurance group number of the plan through which the insurance is provided on Line A (if known). For a list of MSP condition codes, occurrence codes, value codes, payer codes and relationship codes, see MSP Billing Codes on next page For more information about MSP, see the Medicare Secondary Payer Manual (CMS Pub ) available at J a n u a r y 2010 C a h a b a G B A, L L C P a g e 10 o f 11

11 Medicare Secondary Payer (MSP) Billing Codes (FISS Field/UB-04 FL) Condition Codes (COND CODES/FL18-28) Code Description 02 Condition is employment related 03 Patient covered by insurance not reflected here 0 Lien has been filed 0 ESRD patient in first 30 months of entitlement 08 Beneficiary would not provide information concerning other insurance coverage 09 Neither patient nor spouse is employed 10 Patient and/or spouse is employed but no EGHP coverage exists 11 Disabled beneficiary but no LGHP coverage 28 Patient and/or spouse s EGHP is secondary 29 Disabled beneficiary and/or family member s LGHP is secondary to Medicare 77 Provider accepts or is obligated/required due to a contractual agreement or law to accept payment by a primary payer as payment in full. Medicare payment will be made. Occurrence Codes (OCC CDS/DATES / FL31-34) Code Description 01 Auto Accident - beneficiary s medical payment coverage 02 fault insurance involved (use with VC 14) 03 Accident - liability (includes underinsured and uninsured) (use with VC 47) 04 Accident/employment related (use with VC 1) 0 Other accident 0 Crime victim 18 Date of retirement patient/beneficiary 19 Date of retirement spouse 24 Date insurance denied 33 First day of coordination period for ESRD beneficiaries covered by EGHP A3 Benefits exhausted (payer A) Value Codes Payer Codes Description VALUE CODES/FL39-41 PAYER/FL0 Working aged beneficiary/spouse with EGHP 12 A ESRD beneficiary in 30-month coordination period with an EGHP 13 B -fault, including auto/other 14 D Workers compensation 1 E Public health service (PHS) or other federal agency (Ex: crime victim, drug trial) 1 F Black lung 41 H Veteran s administration 42 I Disabled beneficiary under age with large group health plan (LGHP) 43 G 44 Use Amount provider agreed to accept from primary payer when this amount is less appropriate than charges, but higher than payment received, then a Medicare secondary Payer Code payment is due (Enter the total amount you agreed to or are obligated to accept.) A-I or L Liability insurance 47 L Conditional payment (payment denied, applied to deductible, or services unrelated) Any of the above C Relationship Codes (REL/FL9) Code Description Code Description 01 Spouse 23 Sponsored dependent 04 Grandfather/grandmother 24 Dependent of minor dependent 0 Grandson/granddaughter 29 Significant other 07 Nephew/niece 32 Mother 10 Foster child 33 Father 1 Ward 3 Emancipated minor 17 Stepson/stepdaughter 39 Organ donor 18 Self 40 Cadaver donor 19 Child 41 Injured plaintiff 20 Employee 43 Child where insured has no financial responsibility 21 Unknown 3 Life partner 22 Handicap dependent G8 Other relationship For a complete list of all codes, go to the Medicare Claims Processing Manual (CMS Pub , Ch. 2) available at J a n u a r y 2010 C a h a b a G B A, L L C P a g e 11 o f 11